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1 CALIFORNIA STATE UNIVERSITY SAN MARCOS OFFICE FOR TRAINING, RESEARCH AND EDUCATION IN THE SCIENCES (OTRES) LOUIS STOKES ALLIANCE FOR MINORITY PARTICIPATION PROGRAM (CSU-LSAMP) APPLICATION CAMPUS: CSU San Marcos YEAR: Initiated in , CSU LSAMP is an alliance of the 23 campuses of the California State University (CSU) system which supports a coordinated and comprehensive system wide approach to broadening participation in science, technology, engineering and mathematics (STEM) disciplines. Each of the CSU campuses has a CSU LSAMP program that offers an array of activities and services designed to improve retention and graduation of undergraduate students in STEM. In addition, CSU LSAMP seeks to increase the number of CSU LSAMP students who enter STEM graduate programs. To be eligible to participate in CSU LSAMP, students must: Be a U.S. Citizen or Permanent Resident. Be enrolled at a participating campus in an undergraduate major in a STEM discipline or have expressed an interest in pursuing a STEM baccalaureate degree. Be an individual who has faced or faces social, educational, or economic barriers to careers in STEM. Each CSU LSAMP campus program may have additional eligibility requirements. Please see the Campus Coordinator. I certify that my information has not changed. I. GENERAL INFORMATION Name: Address: Last First Middle Street City Zip Code Telephone: ( ) CSUSM ID: Please include area code Date of Birth: Place of Birth: City, State, & Country Gender: Male Female Social Security #: Citizenship: U.S. Citizen Permanent Resident If applicable, Permanent Resident Registration #: Please mark one of the boxes provided for both Ethnicity and Race. Ethnicity (for statistical purposes only): Not Hispanic or Latino Race (for statistical purposes only): Black or African American A person having origins in any of the black racial groups in Africa Hispanic or Latino (A person of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race) Decline to State Native Hawaiian or Other Pacific Islander A person having origins in any of the original peoples of Hawaii, Guam, Samoa, Polynesia, Micronesia, or other Pacific Islands Page 1 of 5

2 American Indian A person having origins in any of the original peoples of North America and maintaining cultural identification through tribal affiliation or community recognition Alaska Native A person having origins in any of the original peoples of Alaska, including Eskimos or Aleuts Asian A person having origins in any of the original peoples of East Asia, Southeast Asia, or the Indian subcontinent. This area includes, for example, China, India, Indonesia, Japan, Korea, and Vietnam White A person having origins in any of the original peoples of Europe, North Africa, or the Middle East Other (specify): Decline to State II. PERSONAL INFORMATION A. Please indicate your parents level of education: Mother: No College Some College College Graduate Graduate School Father: No College Some College College Graduate Graduate School B. Disability Status (again, for statistical purposes only): Please check yes if any of the disabilities listed below the check box apply to you. Otherwise, check no or decline to state. Yes No Decline to State Deaf or serious difficulty hearing Serious difficulty walking or climbing stairs Blind or serious difficulty seeing even when wearing Other serious disability related to a physical, mental, glasses or emotional condition C. Are you a veteran of the U.S. Armed Forces? Yes No Decline to State D. As an undergraduate, are you eligible for need based financial aid? Yes No E. Are you treated as an independent student for financial aid purposes? Yes No F. What is your Personal yearly income? Less than $10,000 $10,001 $20,000 $20,001 $30,000 More than $30,000 G. What is your Family s yearly income? III. EDUCATIONAL INFORMATION Less than $10,000 $10,001 $20,000 $20,001 $30,000 More than $30,000 Major: Class Level: Minor (if any): (e.g. freshman, sophomore, junior, senior) Total Number of Units Completed: Semester Quarter Total Number of Major Units Completed: Semester Quarter G.P.A. (Do not round up): Cumulative GPA GPA in Major Date you expect to receive your CSU Undergraduate Degree: Page 2 of 5

3 Anticipated Undergraduate Degree (BA/BS): List the 3 most recent math and science courses you have taken and the grades Course School Grades Did you transfer from a California Community College? Yes No If yes, which college: If yes, how many units did you complete prior to transferring? Did you complete an Associate s degree? Yes No IV. CAREER GOALS: Write a brief summary of your current career goals and any plans for education after you complete your Bachelor s degree: Page 3 of 5

4 V. Student Signature/Release Please read the statement below and sign where indicated: The information I have submitted in my California State University LSAMPS Application is true and accurate to the best of my knowledge. I understand that to track the progress of the CSU LSAMP students and to evaluate program effectiveness, CSU LSAMP requires access to student information. The CSU LSAMP program is required to report individual student data to the National Science Foundation including social security number, ethnicity, GPA, and enrollment status. This information is also used to study student transfer, retention, progression, and graduation. Photographs and research abstracts may also be obtained for use by the CSU LSAMP program in program dissemination materials such as websites, newsletters, and reports. The student data are collected by the CSU LSAMP Statewide Office at California State University, Sacramento and each of the 23 affiliated Alliance CSU campuses. I authorize release and use of personal information, as described above, to the CSU LSAMP program. I understand that this information is to be used solely for evaluating the impact and effectiveness of the CSU LSAMP program and that individual student data will not be released to parties other than those directly involved with the program. I have read and understand all of the statements above. Printed Signature of Applicant: PLEASE MAIL OR DELIVER COMPLETED APPLICATION TO: Celia Martinez Office for Training, Research and Education in the Sciences Academic Hall 410 California State University San Marcos, San Marcos, CA Page 4 of 5

5 Campus Coordinator Approval and Certification The above named student is approved as a CSU LSAMP student? Yes Is an individual who has faced or faces (check one) social educational economic barriers to careers in STEM. No Does not meet eligibility criteria Printed Name of Campus Coordinator: Signature of Campus Coordinator: Student Acknowledgement TO BE SIGNED BY STUDENT UPON APPROVAL TO PROGRAM I understand that I have been accepted to the CSU LSAMP Program and granted access to the various activities therein. I further understand that I must maintain expectations explained to me by the CSU LSAMP Campus Coordinator for continued involvement in the program. Signed: Page 5 of 5